Request A Kiosk Kiosk Request FormPlease complete this form to begin the process of getting your own Weigh and Win kiosk. After you complete this form, you will be contacted by a Weigh and Win coordinator to discuss next steps. If you have any questions, please contact Lia Schoepke at (303) 694-8012 or lschoepke@weighandwin.com Thank you!0Contact Person*full name1Name of Organization*2Organization Type*Select OneMedical FacilityLibraryRecreation CenterEducationGovernmentOther3# of Employees*4Address*Line 15Address*Line 26City*7State*select your stateSelect OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY8Zip Code*9Phone*XXX-XXX-XXXX10Email*a valid email address11How Did You Hear About Us?*let us know how you heard about us12Organization Logo*used to promote your kiosk locationUpload13Please review the Kiosk Option Guide and choose the kiosk model that best fits your needs.14Select Preferred Kiosk Style*please view link above for explanation of kiosk modelsStationary KioskMobile Kiosk15Comments*anything else you'd like to tell us16Submit17powered by FormCraft form builder